Youth Tennessee Retreat
Name of the Student
First Name
Last Name
Age
Gender
Male
Female
Grade Student Is Going Into
Please Select
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Graduating Senior
Parent or Guardian Phone Number
Please enter a valid phone number.
Is he/she carrying an Epi-pen at all times?
Yes
No
Does the student have any allergies?
Yes
No
What are their allergies?
Does the student have any medical condition that we should be aware of?
Yes
No
What is this medical condition? Please elaborate below:
Emergency Contact Information
Emergency Contact 1
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Payment Details
Pay online by going to antiochbr.com/giving and making a one-time donation to the "youth general" fund. Please reach out if you are interested in fundraising opportunities.
Sign up Fee
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Youth Tennessee Trip
Covers white water rafting, food, travel
$
350.00
Quantity
1
2
3
4
5
6
7
8
9
10
Payment Method
Please Select
Cash (deliver directly to church staff)
Check (deliver directly to church staff)
Online
You do not have to pay upon registration but by registering you are committing to fundraising or paying in full or in installments as soon as possible.
Reminders
I allow my student to participate in this program.
We can provide a refund if you cancel your registration 5 days prior to the start of the trip. If it is below 5 days, then the fees are non-refundable.
I hereby authorize volunteer personnel to conduct first aid, and medical care in the event of an emergency situation. I agreed to pay for all the medical care expenses and costs in a given situation that medical care is needed. (For in-person)
I release the organizers from any liabilities that might happen during the activity and hold them harmless in the event of damages, injuries, or accidents.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Would it be okay if we take photos and videos of the participant during the activity which will be posted in our social media account?
Yes
No
Date
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Month
-
Day
Year
Date
Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: